SMRK5103 Risk Management Full Version Study Guide

STUDY GUIDE SMRK5103 Risk Management
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CENTRE FOR GRADUATE STUDIES
STUDY GUIDE
SMRK5103
Risk Management

Writer: Dr Mohd Rafee Baharudin
Open University Malaysia

Developed by: Centre for Instructional Design and Technology
Open University Malaysia

First Edition, August 2012

Copyright Open University Malaysia (OUM), August 2012, SMRK5103
All rights reserved. No part of this work may be reproduced in any form or by any means
without the written permission of the President, Open University Malaysia.

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Contents

Course Introduction ....................................................................................... 5
Course Synopsis .................................................................................. 5
Course Aims ......................................................................................... 5
Course Outcomes ................................................................................ 6
Course Load ......................................................................................... 6

Course Resources and Requirements ......................................................... 8
Set Textbook(s) .................................................................................... 8
Essential References ........................................................................... 8
Additional Recommended Readings .................................................... 9
My Virtual Learning Environment (myVLE) .......................................... 9
OUM Digital Library Resources ............................................................ 9

Assessment .................................................................................................. 10
Assessment Format ........................................................................... 10
Late Submission of Assignment(s) ..................................................... 10

Topics ........................................................................................................... 11
Topic 1 Introduction to Risk Management ....................................... 11
Topic 2 Risk Strategy ...................................................................... 14
Topic 3 Risk Assessment ................................................................ 17
Topic 4 Risk and Organisations ...................................................... 20
Topic 5 Risk Response ................................................................... 23
Topic 6 Risk Assurance and Reporting ........................................... 26
Topic 7 The Cost of Human Error ................................................... 29

Assessment Guide ....................................................................................... 31
Assignment .............................................................................................. 31
Do Not Plagiarise ..................................................................................... 32
Avoid Plagiarism ...................................................................................... 32
Documenting Sources .............................................................................. 33
Referencing .............................................................................................. 33

Appendix A ................................................................................................... 35
Sample Assignment ................................................................................ 35

Appendix B ................................................................................................... 36
Learning Support ..................................................................................... 36

Appendix C ................................................................................................... 37
Study Paths for Success in the Course ............................................... 37


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COURSE INTRODUCTION
Study Guide
The course SMRK5103 Risk Management is one of the required courses for
the OUM Master of OSH Risk Management (MOSHRM) programme. The
course assumes some prior knowledge and experience of face-to-face
teaching in a classroom and of curricular aspects of courses you have
taught. For this reason, you are encouraged to read widely and to tap into
your work experience to get the most out of the course.
Course Synopsis
The course introduces the subject of risk assessment and control with a
comprehensive perspective on risk concepts, tools and techniques. It
demonstrates critical understanding of the principles and practices of risk
assessment and control.
Course Aims
The course aims to equip students with advanced knowledge and skills in
assessing and managing the risks involved in an industry towards creating a
specialised workforce.
Course Outcomes
By the end of this course, you should be able to:
1. Describe the concept of risk management;
2. Discuss the steps involved in conducting risk assessment;
3. Critically assess risk using different types of tools in evaluating risks;
and
4. Conduct risk assessment and control in various industries.

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Course Load
It is a standard OUM practice that learners accumulate 40 study hours for
every credit hour. As such, for a three-credit hour course, you are expected
to spend at least 120 hours of learning. Table 1 gives an estimation of how
the 120 hours can be accumulated.

Table 1: Allocation of Study Hours
Activities No of Hours
Reading the course guide and completing the exercises 60
Attending 5 seminar sessions (3 hours for each session) 15
Engage in online discussion 10
Completing assignment 20
Revision 15
Total 120

It is important to know that this STUDY GUIDE is organised around a
number of TOPICS, LEARNING OUTCOMES, FOCUS AREAS and
ASSIGNED READINGS. This is illustrated in the figure below.

TOPICS
LEARNING
OUTCOMES
FOCUS
AREAS
ASSIGNED
READINGS
STUDY GUIDE

Figure 1: Organisation of the Study Guide

To achieve the learning outcomes for the course, five TOPICS are included
in the Study Guide. Each of these topics is to be covered in depth, based on
readings from the assigned textbook and supplementary materials for the
course. You are expected to spend about 12 hours of learning time on each
topic. Ideally, a topic should be covered during each seminar.

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Secondly, each topic comprises a number of LEARNING OUTCOMES,
FOCUS AREAS and ASSIGNED READINGS. Each topic is guided by topic-
related learning outcomes which essentially tell you what ought to be
achieved at the end of a topic. The focus areas demonstrate sub-topics that
are to be learnt, understood, applied and evaluated through deliberation. In
addition, these focus areas will be covered in the assignment and the
examination for the course.

Finally, assigned readings cover the core content for each topic. You will
have to read all of what is assigned.

An important point to be raised here is that while the selected topics for the
course SMRK5103 cover a substantial amount of information, your readings
and deliberations should not be limited to these topics or to the assigned
readings. The assigned readings and the focus areas merely tell you about
core content, representing the minimum amount of information to cover. As
in all graduate courses, a wide selection of readings is recommended for full
understanding of the area, which in this case, includes models and strategies
of instruction used by teachers all over the world. It would be worth your
while to read the recommended texts and to search OUMs digital library for
other books and articles related to the course.

The pages that follow outline a list of topics and related learning outcomes,
focus areas as well as assigned readings for the course. Throughout the
duration of the course, your course facilitator will use these topics as a guide
for all face-to-face interaction, class participation and group or online
discussion. At the end of the course, your knowledge and comprehension of
the areas under these topics will be assessed.

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COURSE RESOURCES AND REQUIREMENTS
Set Textbook(s)
Hopkin, P. (2010). Fundamentals of risk management: Understanding,
evaluating and implementing effective risk management. United States:
Kogan Page Limited.
Essential References
Bartlett, J . (2004). Project risk analysis and management guide. United
Kingdom: APM Publishing.
British Standard Institute. (2008). BS31100:2008, Principle of risk
management. United Kingdom: British Standard Institute (BSI).
DOSH. (2008). Guidelines for hazard identification, risk assessment and risk
control (HIRARC). Retrieved from http://www.dosh.gov.my/doshv2/
phocadownload/guidelines/ve_gl_hirarc.pdf
Goetsch. (2011). Occupational Safety and Health for Technologies,
Engineers and Managers (7th ed.). Pearson. Pg. 3 9.
HM Treasury. (2004). The orange book: Management of risk principles and
concepts. Retrieved from http://www.hmtreasury.gov.uk/d/orange_
book.pdf
International Standard IES/FDIS 21010. (2009). Risk management Risk
assessment techniques. Retrieved from www.iso.org
IRM. (2002). A risk management standard. Retrieved from http://www.theirm.
org/publications/documents/Risk_Management_Standard_030820.pdf
ISO. (2009). ISO 31000: 2009 Risk management principles and guidelines.
Retrieved from http://www.iso.org/iso/catalogue_detail?csnumber=
43170
The Institute of Internal Auditors. (2004). The role of internal auditing in
enterprise wide risk management. Retrieved from www.theiia.org.
Vance, B., & Makomaski, J . (2007). Enterprise risk management for
dummies. New J ersey: Wiley Publishing.


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Additional Recommended Readings
Association of Insurance and Risk Managers. (2006). Insurance buyers
guide. Retrieved from www.airmic.com
COSO. (2004). Enterprise risk management integrated framework:
Executive summary. Retrieved from www.coso.org
Ericson, C. A. (2005). Hazard analysis techniques for system safety (2nd
ed.). Wiley-Interscience.
Health and Safety Executive. (2005). A review of safety culture and safety
climate literature for the development of the safety culture: Inspection
toolkit research report 367. Retrieved from http://www.hse.gov.
uk/research/rrpdf/rr367.pdf
Occupational Safety and Health Master Plan for Malaysia 2015 by Ministry of
Human Resources Malaysia.
United States Government. (2004). Every business should have a plan.
Retrieved from www.ready.gov
My Virtual Learning Environment (myVLE)
Online Discussion
Learners are required to participate in online discussions.
Assignment
Learners are required to surf the Internet, visit OUM digital library resources,
and read the recommended textbooks and journals to complete the
assignments.
OUM Digital Library Resources
For the purpose of referencing materials and doing library-based research,
OUM has a comprehensive digital library. For this course, you may use the
following databases: ProQuest, CINAHL Plus, Springer Link and InfoSci
Books. From time to time, materials from these databases will be assigned
for additional reading and activities.

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ASSESSMENT
Assessment Format
Refer to myVLE.
Late Submission of Assignment(s)
Failure to submit an assignment by the due date without the granting of an
official extension of time by your course tutor will incur a penalty.

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Topics

Topic 1: Introduction to Risk Management
Learning Outcomes
By the end of this topic, you should be able to:
1. Describe a range of definitions of risk and risk management, and the
usefulness of the various definitions;
2. List the characteristics of a risk that need to be identified in order to
provide a full risk description;
3. Describe options for classifying risks according to the nature, source
and timescale impact;
4. Outline the options for the attachment of risks to various attributes of
an organisation and the advantages of each approach;
5. Use a risk matrix to represent the likely impact of risk materialising in
terms of likelihood and magnitude;
6. Outline the principles (PACED) and aims of risk management and its
importance to operations, projects and strategy;
7. Describe the nature of hazard, control and opportunity risks and how
organisations should respond to each type;
8. Outline the development of the discipline of risk management, including
the various specialist areas and approaches;
9. Describe the key benefits of risk management in terms of compliance,
assurance, decisions and efficiency/efficacy (CADE3);
10. Describe the key stages in the risk management process and the main
components of a risk management framework; and
11. Describe the key features of the best-established risk management
standards and frameworks.


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Focus Areas Assigned Readings

1.1 Approaches to Defining
Risk

1.2 Impact of Risk
Organisations

1.3 Types of Risks

1.4 Development of Risk
Management

Hopkin, P. (2010). Fundamentals of risk
management: Understanding, evaluating and
implementing effective risk management. United
States: Kogan Page Limited.

Chapter 1 Approaches to Defining Risk
Definitions of risk.
Types of risks.
Risk description.
Inherent level of risk.
Risk classification systems.
Risk likelihood and magnitude.
Chapter 2 Impact of Risk on Organisations
Risk importance.
Impact of hazard risks.
Attachment of risks.
Risk and reward.
Risk and uncertainty.
Attitude to risk.

Chapter 3 Types of Risks
Timescale of risk impact.
Hazard, control and opportunity risks.
Hazard tolerance.
Management of hazard risks.
Uncertainty acceptance.
Opportunity investment.

Chapter 4 Development of Risk Management
Origins of risk management.
Insurance origins of risk management.
Specialist areas of risk management.
Enterprise risk management.
Levels of risk management
sophistication.
Risk maturity models.


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1.5 Principles and Aims of
Risk Management

1.6 Risk Management
Standards

Chapter 5 Principles and Aims of Risk
Management
Principles of risk management.
Importance of risk management.
Risk management activities.
Efficient, effective and efficacious.
Perspective of risk management.
Implementing risk management.
Chapter 6 Risk Management Standards
Scopes of risk management standards.
Risk management process.
Risk management framework.
COSO ERM cube.
Features of risk management standards.
Control environment approach.

Guidelines for Hazard Identification, Risk
Assessment and Risk Control (HIRARC) by
DOSH Malaysia, Ministry of Human Resources
Malaysia 2008.

Pg. 5 16.
Risk Management Concept in Malaysia
Basic Concepts
Planning and Conducting of HIRARC
Control

Study Questions
1. Discuss the PACED concept.
2. Discuss the options of classifying risks according to the nature, source
and timescale impact.
3. Discuss the nature of hazard, control and opportunity risks and how
organisations should respond to each type.


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Topic 2: Risk Strategy
Learning Outcomes
1. Describe the main parts of risk management policy and the importance
of each part;
2. Explain the key components of the risk architecture, strategy and
protocols (RASP) for an organisation and how these fit together;
3. Describe the range of risk documentation and records that could be
required and the function of each different type;
4. Describe the nature, content and use of a risk register, citing examples;
5. Outline the key roles and responsibilities of risk management in relation
to job roles and key departments, including the role of CRO;
6. Describe suitable risk architecture for a range of organisations,
including the importance of risk committees and risk communication;
7. Describe the key features of a risk-aware culture (LILAC) and how the
key components can be measured;
8. Describe the components of evaluating risk maturity of an organisation
(4Ns) and the benefits associated with greater risk maturity; and
9. Outline the importance of risk training and risk communication,
including the use of a risk management information system (RMIS).


2.1 Risk Management Policy

implementing effective risk management.
United States: Kogan Page Limited.

Chapter 7 Risk Management Policy
Risk architecture, strategy
and protocols.
Risk management policy.
Risk management
architecture.
Risk management strategy.


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2.2 Risk Management
Documentation

2.3 Risk Management
Responsibilities

2.4 Risk Architecture and
Structure

Risk management protocols.
Risk management
guidelines.

Chapter 8 Risk Management Documentation
Record of risk management
activities.
Risk response and
improvement plans.
Event reports and
recommendations.
Risk performance and
certification reports.
Designing a risk register.
Using a risk register.

Documenting HIRARC
Responsibility and Accountability
Documenting Process

Guidelines for Hazard Identification, Risk
Assessment and Risk Control (HIRARC) by
DOSH Malaysia, Ministry of Human Resources
Malaysia 2008.
Pg. 16 17.

Chapter 9 Risk Management Responsibilities
Allocation of responsibilities.
Risk management and
internal audit.
Range of responsibilities.
Statutory responsibilities of
management.
Role of risk manager.
Chief Risk Officer (CRO).

Chapter 10 Risk Architecture and Structure
Risk architecture.
Corporate structure.
Risk committees.


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2.5 Risk-Aware Culture

2.6 Risk Training and
Communication

Risk communications.
Risk maturity.
Alignment of activities.

Chapter 11 Risk Aware Culture
Styles of risk management.
Defining risk culture.
Components of a risk-aware
culture.
Measuring risk culture.
Risk culture and risk
steategy.
Establishing the context.
Chapter 12 Risk Training and
Communication
Risk training and risk culture.
Risk information and
communication.
Shared risk vocabulary.
Risk information on an
intranet.
Risk Management
Information System (RMIS).
Consistent response to risk.

Study Questions
1. Discuss the key features of a risk-aware culture (LILAC) and how the
key components can be measured.
2. Discuss the main parts of a risk management policy and the
importance of each part.


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Topic 3: Risk Assessment
Learning Outcomes
1. Describe the importance of risk assessment as a critically important
stage in the risk management process;
2. Outline the range of risk assessment techniques that are available and
the advantages/disadvantages of each technique;
3. Describe the importance of risk classification systems and the key
features of the best-established systems;
4. Provide examples of the use of a risk matrix, including using it to
indicate the dominant risk response in each quadrant;
5. Use a risk matrix to indicate the risk appetite of an organisation and
whether the organisation is risk averse or risk aggressive;
6. Describe the main components of loss control as loss prevention,
damage limitation and cost containment and provide practical
examples;
7. Demonstrate the use of loss-control actions to reduce the impact of an
event that has a large magnitude before mitigation;
8. Outline the alternative approaches to define the upside of risk and the
practical application of these approaches for strategy, projects and
operations;
9. Outline the importance of business continuity planning and disaster
recovery planning and provide practical examples;
10. Describe the approach taken during a business impact analysis and
how the analysis supports business continuity planning; and
11. Describe the key features of a business continuity plan, as set out in
established business continuity standards, such as BS 25999.


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3.1 Risk Assessment
Considerations

3.2 Risk Classification Systems

3.3 Risk Likelihood and Impact


Chapter 13 Risk Assessment Considerations
Importance of risk
assessment.
Approaches to risk
assessment.
Risk assessment
techniques.
Risk matrix.
Risk perception.
Risk appetite.

Chapter 14 Risk Classification Systems
Short, medium and long-
term risks.
Purpose of risk classification
systems.
Examples of risk
classification systems.
FIRM risk scorecard.
PESTLE risk classification
system.
Hazard, control and
opportunity risks.

Chapter 15 Risk Likelihood and Impact
Application of a risk matrix.
Inherent and current level of
risk.
Control confidence.
4Ts of risk response.
Risk significance.
Risk capacity.


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3.4 Loss Control

3.5 Defining the Upside Of Risk

3.6 Business Continuity Planning

Chapter 16 Loss Control
Risk likelihood.
Risk magnitude.
Hazard risks.
Loss prevention.

Damage limitation.
Cost containment.

Chapter 17 Defining the Upside of Risk
Upside of risk.
Opportunity assessment.
Riskiness index.
Upside in strategy.
Upside in projects.
Upside in operations.

Chapter 18 Business Continuity Planning
Importance of BCP and
DRP.
Business continuity
standards.
Successful BCP and DRP.
Business impact analysis
(BIA).
BCP and ERM.
Civil emergencies.

Study Questions
1. Discuss the range of risk assessment techniques that are available as
well as the advantages and disadvantages of each technique.
2. Discuss the key features of a business continuity plan.


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Topic 4: Risk and Organisations
Learning Outcomes
1. Describe the key features of a corporate governance model and the
links to risk management in different types of organisations;
2. Describe the different types of stakeholders of a typical organisation
and the influence of these stakeholders on risk management;
3. Describe a simplified business model and the different types of core
processes that need to take place in an organisation;
4. Provide a brief description of the project life cycle and the importance
of risk management at each stage, using the 4As approach;
5. Describe the key features of a project risk management system, such
as the Project Risk Analysis and Management (PRAM) approach;
6. Outline the key features of operational risk as practised in financial
institutions, such as banks and insurance companies;
7. Describe the key sources of operational risk in financial institutions and
provide examples of how these risks are managed;
8. Describe the importance of the supply chain and the contribution of
supply chain risk management to the success of the organisation; and
9. Give examples of the risks associated with outsourcing and how these
risks can be successfully managed.


4.1 Corporate Governance
Model


Chapter 19 Corporate Governance Model
Corporate governance.
OECD principles of
corporate governance.
LSE corporate governance
framework.


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4.2 Stakeholder Expectations

4.3 Analysis of the Business
Model

4.4 Project Risk Management

4.5 Operational Risk Management

Corporate governance for a
bank.
Corporate governance for a
government agency.
Evaluation of board
performance.

Chapter 20 Stakeholder Expectations
Range of stakeholders.
Stakeholder dialogue.
Stakeholders and core
processes.
Stakeholders and strategy.
Stakeholders and tactics.
Stakeholders and
operations.

Chapter 21 Analysis of the Business
Model
Simplified business model.
Core business processes.
Efficacious strategy.
Effective processes.
Efficient operations.
Reporting performance.

Chapter 22 Project Risk Management
Introduction to project risk
management.
Development of project risk
management.
Uncertainty in projects.
Project life cycle.
Opportunity in projects.
Project risk analysis and
management.

Chapter 23 Operational Risk Management
Operational risk.
Definition of operational
risk.

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4.6 Supply Chain Management

Basel II.
Measurement of operational
risk.
Difficulties of measurement.
Development in operational
risk.

Chapter 24 Supply Chain Management
Importance of the supply
chain.
Scope of the supply chain.
Strategic partnerships.
J oint ventures.
Outsourcing of operations.
Risk and contracts.

Study Questions
1. Discuss the project life cycle and the importance of risk management at
each stage, using the 4As approach.
2. Discuss the key features of a project risk management system, such as
the PRAM approach.


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Topic 5: Risk Response
Learning Outcomes
1. Provide alternative definitions of Enterprise Risk Management (ERM);
2. Identify the key features of an enterprise-wise approach;
3. Describe the ten steps in the implementation of a successful ERM
initiative;
4. Outline the importance of risk appetite as a planning tool in the
implementation of a risk management initiative;
5. Describe the relationship between risk appetite, risk exposure and risk
capacity and the interface with operations, projects and strategy;
6. Describe risk response options in terms of tolerate, treat, transfer and
terminate, and how these can be shown on a risk matrix;
7. Describe the types of controls that are available, in terms of Preventive,
Corrective, Directive and Detective (PCDD) controls;
8. Explain how to determine whether controls are cost effective, how
controls change loss expectancy and how to learn from controls;
9. Provide practical examples of the control of selected hazard risks,
including risks to finances, infrastructure, reputation and marketplace;
10. Describe the importance of insurance and the circumstances in which
insurance is purchased, including the involvement of a captive
insurance company; and
11. Explain the importance of the insurance purchasing process of cost,
coverage, capacity, capabilities, claims and compliance.


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5.1 Enterprise Risk Management

5.2 Importance of Risk Appetite

5.3 Tolerate, Treat, Transfer and
Terminate

5.4 Risk Control Techniques


Chapter 25 Enterprise Risk Management
Enterprise-wide approach.
Definitions of ERM.
ERM in practice.
ERM and business
continuity.
ERM in energy and finance.
Future development of
ERM.

Chapter 26 Importance of Risk Appetite
Risk capacity.
Risk exposure.
Nature of risk appetite.
Cost of risk controls.
Risk management and
uncertainty.
Risk appetite and lifestyle
decisions.

Chapter 27 Tolerate, Treat, Transfer and
Terminate
The 4Ts of hazard
response.
Risk tolerance.
Risk treatment.
Risk transfer.
Risk termination.
Project and strategic
response.

Chapter 28 Risk Control Techniques
Hazard risk zones.
Types of controls.


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5.5 Control of Selected Hazard
Risks

5.6 Insurance and Risk Transfer

Preventive controls.
Corrective controls.
Directive controls.
Detective controls.

Chapter 29 Control of Selected Hazard
Risks
Risk control.
Control of financial risks.
Control of infrastructure
risks.
Control of reputational
risks.
Control of marketplace
risks.
Learning from controls.

Chapter 30 Insurance and Risk Transfer
Importance of risk transfer.
History of insurance.
Type of insurance cover.
Evaluation of insurance
needs.
Purchase of insurance.
Captive insurance
companies.

Study Questions
1. Discuss the importance of risk appetite in an organisation.
2. Discuss the applications of PCDD control measures in managing risks.


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Topic 6: Risk Assurance and Reporting
Learning Outcomes
1. Describe the purpose and nature of internal control and the contribution
that internal control makes to risk management;
2. Outline the importance of the control environment in an organisation
and provide a structure of evaluating the control environment (CoCo);
3. Describe the activities of a typical internal audit function and the
relationship between internal audit and risk management;
4. Describe the activities involved in the ERM initiative and how these can
be allocated to internal audit, risk management and line management;
5. Outline the importance of risk assurance and identify the sources of
risk assurance that are available to the board/audit committee;
6. Discuss the importance of risk reporting and the range of risk reporting
obligations placed on companies, including Sarbanes-Oxley;
7. Provide examples of risk reporting approaches adopted by different
types of organisations, including companies, charities and government
agencies;
8. Describe the importance of corporate social responsibility as a
component of corporate governance and outline the range of topics
covered; and
9. Describe the steps involved in the successful implementation of a risk
management initiative, together with the barriers and actions.


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6.1 Evaluation of the Control
Environment

6.2 Activities of the Internal Audit
Function

6.3 Risk Assurance Techniques

6.4 Reporting on Risk
Management


Chapter 31 Evaluation of the Control
Environment
Nature of internal control.
Purpose of internal control.
Control environment.
Features olf the control
environment.
CoCo framework of internal
control.
Risk aware culture.

Chapter 32 Activities of the Internal Audit
Function
Scope of internal audit.
Financial assertions.
Risk management and
internal audit.
Risk management outputs.
Role of internal audit.
Management
responsibilities.

Chapter 33 Risk Assurance Techniques
Audit committees.
Role of risk management.
Risk assurance.
Hazard, control and
opportunity risks.
Control of risk self-
assessment.
Benefits of risk assurance.

Chapter 34 Reporting on Risk Management
Risk documentation.


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6.5 Corporate Social
Responsibilities

6.6 Future of Risk Management

Sarbanes-Oxley Act of
2002.
Risks reported by US
companies.
Charities risk reporting.
Public sector risk reporting.
Government report on
National Security.

Chapter 35 Corporate Social
Responsibilities
CSR and corporate
governance.
CSR and risk management.
CSR and reputational risk.
CSR and stakeholder
expectations.
Supply chain and ethical
trading.
CSR reporting.

Chapter 36 Future of Risk Management
Review of benefits of risk
management.
Steps to successful risk
management.
Changing fact of risk
management.
Concept of risk appetite.
Concept of upside of risk.
Future developments.

Study Questions
1. Discuss the activities of a typical internal audit function and the
relationship between internal audit and risk management.
2. Discuss the steps involved in the successful implementation of a risk
management initiative, together with the barriers and actions.

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Topic 7: The Cost of Human Error
Learning outcomes
1. Describe the key features of a risk-aware culture (LILAC); and
2. Explain how the key components can be measured.

Focus Area Assigned Readings

7.1 Learning from the Past

7.2 The Need for Safety

7.3 Safety Culture

Goetsch. (2011). Occupational Safety and
Health for Technologists, Engineers and
Managers (7th ed.). Pearson. Pg. 3 9.

Safety and Health Movement, Then and Now
Developments Before the Industrial
Revolution
Milestones in the Safety Movement
Tragedies that have Changed the Safety
Movement

OSH Current Situation
Rates of Occurrence of Occupational
Accidents and Fatalities
Comparison of OSH Performance Profiles
between Malaysia and Other Countries in
East Asia
National Competitiveness Index Versus
National Occupational Fatality Occurrence
Rate
OSH Contribution to the Malaysian Quality
of Life

OSH Culture Establishment
Long Term Vision for OSH in Malaysia
Safety Culture A Tool in Sustaining
Productive Human Capital

Occupational Safety and Health Master Plan for
Malaysia 2015 by Ministry of Human Resources
Malaysia.


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7.4 Understanding Human
Error

Goetsch. (2007). Occupational safety and
health for technologists, engineers and
managers (7th ed.). Pearson. Pg. 34 36.

Human Factors Theory of Accident Causation
Overload
Inappropriate Response and Incompatibility
Inappropriate Activities
Huma Factors Theory in Practice

Study Questions
1. Explain how workplace tragedies have affected the safety movement.
Give examples.

2. Discuss the importance for organisations to establish safety culture.

3. Using your organisation as an example, explain how it is able to realise
OSH-MP15.


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Assessment Guide

Refer to myVLE.
Assignments
There is one assignment in this course. Commonly, the assignment will be
focusing on the application of OSH legal requirements for the purpose of an
organisations relevant legal compliance. The assignment questions will be
assessed from OUM`s Virtual Learning Environment (myVLE). It is your
responsibility to make sure that your assignment reaches the course
coordinator within the time frame.

The objective of the assignment is mainly to give you an opportunity to
explore and analyse OSH legal requirements in depth. You are encouraged
to use critical thinking in your assignment especially for the application of
theories into practice. The assignment is guided by the contents of the
recommended textbook and recent journals.

As mentioned earlier, graduate students must demonstrate that they have
read widely and researched their topic well. It is NOT sufficient to rely on
information in the assigned textbook or in the Course Guide to complete your
assignment. Using a variety of references will give you a broader perspective
on the various topics and will provide a deeper understanding of the subject.

The criteria for the assessment of this assignment cover content, structure
and thinking skills. In general, you are required to write clearly, using correct
spelling and grammar. You also have to submit a paper that shows evidence
of the following:
(a) Reflection: Reflect critically on issues raised in the course.
(b) Deliberation: Consider and appreciate a range of points of view,
including those included in the course material.
(c) Application: Develop your own view with regard to application of the
concepts and focus areas covered in the course.
(d) Argument: State your argument clearly with supporting evidence from
related research and demonstrate appropriate referencing of sources.

32
(e) Integration: Draw on your own experiences and integrate the
information in the course assignment.
Do Not Plagiarise
As a graduate student, remember that your own thinking and the knowledge
you construct as a participant in a course are integral to learning. To
succeed in the course, you should never resort to plagiarism or copying at
any level whatsoever. Plagiarism refers to any form of deception in a
written paper (such as assignments or essays) by a student. It is intended
to deceive the instructor about the students abilities or knowledge or the
amount of work that is actually contributed by the student. Here are some
examples sourced from a local site (www.ppl.upm.edu.my).
1. Copying large sections of a paper from the Internet or print sources and
not acknowledging these sections as quotations.
2. Paraphrasing or restating someones argument without acknowledging
the author. Remember that detailed arguments from clearly identifiable
sources must always be acknowledged.
3. Purchasing or buying essays or papers written by other students.
4. Taking credit for work produced by someone else. This includes
photographs, charts, graphs, drawings, statistics, video clips, audio
clips, verbal exchanges such as interviews or lectures, performances
on television and texts printed on the web.
5. Taking double credit by submitting the same essay for two or more
courses.
Avoiding Plagiarism
Here are some ideas from www.ppl.upm.edu.my for avoiding plagiarism in
your assignments and essays.
1. Insert quotation marks around "copy and paste" clauses, phrases,
sentences or paragraphs and cite the original source.
2. Paraphrase clauses, phrases, sentences or paragraphs in your own
words and cite your source.
3. Adhere to the American Psychological Association (APA) stylistic
format, when citing a source and when writing out the bibliography or
reference page.
4. Write independently without being overly dependent on information
from others.

33
5. Original work. Read a text, put it away and then write about what your
have read in your own words.
6. Educate yourself on what may be considered common knowledge (no
copyright necessary), public domain (copyright has expired or not
protected under copyright law), or copyright (legally protected).
Documenting Sources
Remember that when you quote, paraphrase, summarise or refer to
someones work you are required to cite the source. Here are some of the
most commonly cited forms of material (See www.jfklibrary.org,
library.duke.edu/research/citing and www.ppl. upm.edu.my).

Direct citation
using quotation
marks

Simply having a list of thinking skills is no assurance that
children will use it. In order for such skills to become part
of day-to-day behaviour, they must be cultivated in an
environment that values and sustains them. J ust as
childrens musical skills will likely lay fallow in an
environment that doesnt encourage music, learners
thinking skills tend to languish in a culture that doesnt
encourage thinking (Tishman, Perkins and Jay, 1995,
p.5).
Indirect Citation
using referential

According to Wurman (1988), the new disease of the
21
st
century will be information anxiety, which has been
defined as the ever-widening gap between what one
understands and what one thinks one should
understand.
Referencing
All sources that you cite in your paper should be listed in the REFERENCE
section at the end of your paper. Below are some suggestions, as listed in
library.fayschool.org/ Pages/Citation_Guide.htm
From a J ournal Brown, E. (1996). The lake of seduction: Silence,
hysteria, and the space of feminist theatre. JTD:
Journal of Theatre and Drama, 2, 175-200.
From an Online
J ournal
Evnine, S. J . (2001). The universality of logic: On the
connection between rationality and logical ability
[Electronic version]. Mind, 110, 335-367.

34
Retrieved J anuary 12, 2008, from PsyCARTICLES
database.
From a
Webpage
National Park Service. (2003, February 11). Abraham
Lincoln Birthplace National Historic Site. Retrieved
February 13, 2003, from http://www.nps.gov/abli/

From a Book Fleming, T. (1997). Liberty! The American Revolution.
New York: Viking.
From an Article
in a Book

Cassel, J ., & Zambella, B. (1996). Without a net:
Supporting ourselves in a tremulous atmosphere.
In T. W. Leonhardt (Ed.), "LOEX" of
the West: Teaching and learning in a climate of
constant change (pp. 75-92). Greenwich, CT: J AI
Press Inc.
From a Printed
Newspaper
Holden, S. (1998, May 16). Frank Sinatra dies at 82:
Matchless stylist of pop. The New York Times, pp.
A1, A22-A23.


35
Appendix A

Assignment
SMRK5103 RISK MANAGEMENT
Objective:
The purpose of this assignment is to analyse organisational risks based on
different RAM.

The task

You are given TWO articles entitled:

1. A semi-quantitative assessment of occupational risks using bow-tie
representation.

2. Appraisal of a new assessment model for SME.

Read the articles given and answer the following questions.

For each article, DISCUSS the methodology used in assessing risks. Your
discussion should include but is not limited to:
(i) The suitability of the method in assessing risks;
(ii) Coverage or scope of risks;
(iii) The advantage of the Risk Assessment Matrix (RAM) used;
(iv) The limitation of the RAM used; and
(v) Suggestions to further improve the risks assessment methodology.

(60 marks)


36
Appendix B

Learning Support
SMRK5103 RISK MANAGEMENT
Seminars
There are 15 hours of face-to-face facilitation provided for the course. There
will be FIVE seminars of three hours each. You will be notified of the dates,
times and location of these seminars, together with the name and e-mail
address of your facilitator, as soon as you are allocated a group.
Discussion and Participation
Besides the face-to-face seminars, you have the support of online
discussions in myVLE with your facilitator and your coursemates. Your
contributions to the online discussion will greatly enhance your
understanding of course content, and help you do the assignment and
prepare for the examination.
Feedback and Input from Facilitator
As you work on the activities and the assigned text, your course facilitator
will provide assistance to you throughout the duration of the course. The
facilitator will also mark your assignment and give you feedback on your
performance. At any time that you need assistance, do not hesitate to
discuss your problems with your facilitator. The seminars and the online
forum can also be used for any of the following situations:
When you have difficulty with the contents of the textbook or if you do not
understand the assigned readings.
When you have a question or problem with the assignment.
Bear in mind that communication is important for you to be able to get the
most out of this course. Therefore you should, at all times, be in touch with
your facilitator and coursemates, and be aware of all the requirements for
successful completion of a course.


37
Appendix C

Study Paths for Success
Time Commitments for Study
You should plan to spend about six hours of study time on each topic, which
includes the time spent doing all assigned readings and activities. You must
schedule your time to discuss the work online and spend enough time on
each topic for this course. It is often more effective to distribute the study
hours over a number of days rather than spending the whole day studying
one topic. You have some flexibility as there are 10 topics spread over a
period of 15 weeks.
Study Strategy
The following is a proposed strategy for working through the course. If you
have difficulty following the strategy, discuss your problems with your
facilitator either through the online forum or during the seminars.
(i) The most important step is to read the contents of this Course Guide
thoroughly.
(ii) Organise a study schedule. Take note of the amount of time you spend
on each topic, as well as the dates for submission of the assignments
and seminars.
(iii) Once you have created a study schedule, make every effort to stick to
it. One reason students are unable to cope with postgraduate courses
is that they delay their course work.
(iv) To understand the various dimensions of the course, do the following:
Study the Course Overview and the entire list of topics. Then
examine the relationship of a topic to other topics.
Complete all assigned readings and go through the supplementary
texts to get a broad understanding of course content.
Do all activities and read the Scenarios in the assigned textbook to
understand the various concepts and facts presented in a topic.

38
Draw ideas from a large number of readings as you prepare for the
assignment. Work on the assignment as the semester progresses
so that you are able to systematically produce a commendable
portfolio or paper.
(v) When you have completed a topic, review the Learning Outcomes for
the topic to confirm that you have achieved them and are able to do
what is required.
(vi) After completing all topics, review the course content to prepare for the
final examination. Review the Learning Outcomes of the course to see
if you have covered all the relevant parts of the course.

Appraisal of a new risk assessment model for SME
M. Fera, R. Macchiaroli
*
Dipartimento di Ingegneria Aerospaziale e Meccanica, Seconda Universit di Napoli, Real Casa dellAnnunziata, Via Roma, 29, 81041 Aversa (CE), Italy
a r t i c l e i n f o
Article history:
Received 9 November 2009
Received in revised form 21 April 2010
Accepted 14 May 2010
Keywords:
Risk assessment
Safety at work
FMECA
SCEBRA
AHP
a b s t r a c t
The identication, assessment and reduction of the risks is among of the most important issues of the
safety at work. This papers goal is to demonstrate the effectiveness of a new risk assessment method pro-
posed by the authors and presented in the past (Fera and Macchiaroli, 2009). In general, one can deal with
risk assessment using different methods: quantitative, qualitative or a mix; however, the typical models
proposed in the literature are difcult to implement in SMEs. The method proposed in this paper is a
mixed one whose effectiveness is demonstrated through an application study carried out in different
industrial systems, like a steel industry or a logistic services provider.
2010 Elsevier Ltd. All rights reserved.
1. Introduction
The injuries statistics (Table 1) released by the International
Labour Organization (ILO) for 2007 are very signicant.
They show how health and safety problems are very far from
being solved. It is well known that an effective approach to health
and safety at work needs a suitable risk assessment phase, the
adoption of prevention and protection actions and the implemen-
tation of a severe safety audit phase. However, less attention has
been paid to these phases in the practice, using non-appropriate
tools and methodologies which are either too complex to manage
or too simple and subjective, thus not suitable to recognize hazards
and reduce the corresponding risks.
The aim of this paper is to assess the effectiveness of a new and
reliable assessment model presented in Fera and Macchiaroli
(2009), able to face the aforesaid applicability difculties of the
models developed so far and to show, through its application to
several industrial plants, how an improvement in safety condition
can actually be achieved. The proposed model is based on known
techniques, such as Failure Modes and Effects Criticality Analysis
(FMECA), Scenario Based Risk Assessment (SceBRA) and Italian
standard UNI 7249:2007. These techniques are integrated within
a procedure composed by seven steps, some quantitative and some
qualitative. This model also includes the Analytic Hierarchy Pro-
cess (AHP) decision making technique, which as well known
is useful to minimize inconsistencies in experts judgments, within
the subjective phases of risk assessment.
The paper is organized as follows. After discussing the main fea-
tures of relevant models presented in the literature and the open is-
sues in risk assessment, Section 3 contains a brief overview of the
AHP technique in order to underline its importance in the proposed
model. Afterwards, the proposed model is described in detail,
including a discussion about its main features and advantages. Be-
fore concluding, we also report the results from an experimental
campaign carried in three manufacturing and services rms.
2. Literature review and open issues
The identication and choice of a suitable risk assessment mod-
el has been felt as a crucial issue for decades. So far, models used in
the practice were developed for different applications and adapted
for health and safety at work. A possible classication is presented
in Table 2.
Please note that qualifying methods as quantitative or qual-
itative does not mean they are objective or subjective. So, in this
paper we refer to quantitative or qualitative to indicate whether
a method makes use of numerical data or not, while we refer to
a subjective method when it mainly relies on experts judgment.
Since the judgment, in turn, can be qualitative or quantitative, in
the last case we also refer to the corresponding method as quali-
quantitative.
Thus, subjective methods are focused on the experts contribu-
tion. Experts are responsible to predict the possible interactions
between workers, machines and work environment. Subjective
models cannot be implemented in all kind of rms, because of their
intrinsic uncertainty which makes them not suitable for several
applications; think, in example, to risk assessment in the chemical
0925-7535/$ - see front matter 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ssci.2010.05.009
* Corresponding author. Tel.: +39 0815010339; fax: +39 0815010204.
E-mail address: roberto.macchiaroli@unina2.it (R. Macchiaroli).
Safety Science 48 (2010) 13611368
Contents lists available at ScienceDirect
Safety Science
j our nal homepage: www. el sevi er . com/ l ocat e/ ssci
or oil & gas industry, where generally sophisticated reliability
models can and must be applied, and normally lead to a wide ex-
tent of success. Instead, subjective models can be used with good
results in the non industrial environments. In the international lit-
erature there are some contributions about risk assessment for
shing vessels (Piniella et al., 2009), using a check-lists method,
or for large transport networks and urban systems (Chen et al.,
2009). Other authors (Van Duijne et al., 2008) developed a subjec-
tive assessment model based on the European guidelines RAPEX,
used for food quality and safety assurance. Another subjective
method example is the DELPHI analysis, which is a structured
method that gives a hierarchy of the decisions to be evaluated
and achieves a nal decision through verbal experts judgements.
These models are often used in SMEs due to their simplicity,
although in some cases their application can be misleading, as
underlined by many authors (Hetherington et al., 2006; Wirth
et al., 2008; Lingard et al., 1997).
Quantitative models, both objective and subjective, are widely
used in many elds, like in large industrial rms or in the oil and
gas industries. These models make an extensive use of reliability
analysis and, thus, are based on process decomposition techniques
and failures likelihoods knowledge. Indeed, several works are
based on the Bayesian approach for fault tree analysis or for event
trees analysis (Martn et al., 2009; Doytchev et al., 2008). The sta-
tistical approach is also used for other types of risk assessment
models, as for the Bow-Tie ones (Ale et al., 2008). The Bow-Tie
models are based on the identication of a link between causes
and effects of events, and identify a direct quantitative relation be-
tween risk sources and risk consequences. A likelihood is associ-
ated to all possible paths from a cause to an effect, that is, an
expression of the relative importance of a specic risk as connected
to a risk source. Objective methods are used to assess risks in the
chemical industry (Glickman et al., 2007; Brito et al., 2009) or in
the coal mines (Sari et al., 2009); in these sectors safety is often re-
lated to specic possible accidents, whose severity justies the
adoption of quantitative evaluation techniques.
Existing literature reports some works using mixed quali-quan-
titative methods. Some authors apply typical techniques of knowl-
edge analysis, as fuzzy theory (Grassi et al., 2009), trying to
formalize and quantify subjective aspects, treated as fuzzy vari-
ables. Other contributions on this issue are given by the application
of techniques such as the well known HAZOP method and the FSA,
that was developed and suggested to be applied in the maritime
eld by International Maritime Organization (IMO) (IMO, 2002).
The FSA is a structured and systematic approach to assess complex
situations. Examples of its application are reported in the literature
(Hu et al., 2007; Wang, 2002; Ventikos and Psaraftis, 2004). The
FSA method is a structured and costly method, therefore as
underlined by several authors it was mainly used in the maritime
sector, but its application to other, less capital intensive sectors, is
not easily justiable. Among the works appeared in the literature,
it is worth to mention the contribution by Hu et al. on 2007, who
propose an integration between the FSA and fuzzy methods.
Starting from our rst need, i.e., to create a model suitable and
effective for SMEs, that goes beyond the objective and quantitative
models complexity and the non-effectiveness of subjective models,
we explored the possibility to create a model for this kind of rms
based on an approach which represents a compromise between the
different models. The absence in the existing literature of a such a
model and the need for an improvement in existing safety assess-
ment tools for SMEs, convinced us that there is space for working
on mixed quali-quantitative methods. The lack of such approaches
can be due, in our opinion, to the little attention paid so far to
safety in the small and medium enterprises (SMEs) by researchers
and practitioners. This fact, in turn, might be due to the higher
interest paid by them to larger industrial rms, which in a rst
analysis could be identied as a major risk source, while all sta-
tistics show, instead, that most part of injuries and deaths are more
likely to occur in SMEs. For all the reasons mentioned so far, the
purpose of this work is to propose a mixed risk assessment meth-
od, able to overcome the practical difculties generally found by
SMEs in the application of objective and quantitative techniques
(also due to the higher skills required to this aim) and to ll the
gap between the results obtained by the application of subjective
approaches, generally employed, and the need for a reliable risk
assessment.
One of the foreseen advantages of the proposed method is that,
without using costly objective or mixed methods, it allows to
achieve a good match between the results of the risk assessment
and actual risk relevance. In other words, this means that the pro-
posed method achieves better results using similar resources.
3. The Analytic Hierarchy Process (AHP) framework
The AHP (Saaty, 2000) is a technique used in decision making.
Based on the contribution of different experts, it aims at the crea-
tion of a unique priority index for each possible decision, that sum-
marises all experts judgments, minimizing their inconsistency. In
general, the procedure, given an objective and given a set of possi-
ble choices and/or decisions to achieve that goal, calls the experts
to express a relative judgment of relevance of each choice, when
compared to all the others.
The main difference between AHP and the DELPHI method,
mentioned before, is that the AHP technique is not simply based
on verbal judgements but also makes use of quantitative
evaluations.
So, given a set of possible decisions, D = [D
1
, D
2
, . . . , D
n
], the ex-
pert has to indicate a relevance judgment of each decision com-
pared with all the others, examined one by one. Each expert
gives a relevance judgment, that could be named j
kil
, where k and
i are the counter of all the decisions belonging to the set D and l
is the counter of the lth expert. All judgments for each couple of
decisions (D
k
, D
j
), will be synthesized using a geometrical mean
through (1).
j
ki

j
ki1
j
ki2
. . . j
kin
n
q
1
Table 1
Worldwide 2007 injuries and deaths.
Type of injury Number of injuries
Workplace injury 250.000.000 inj/year
8 inj/s
Children workplace injuries 12.000.000 inj/year
Deaths 1.300.000 death/year
Table 2
Methods for the health and safety risk assessment.
Qualitative
What if? analysis
Safety review
Check lists
Quantitative
Fault tree analysis
Events tree
Bow-Tie model
Quali-Quantitative
Hazards and Operability Study (HAZOP)
Failure Methods and Critical Analysis (FMECA)
Formal Safety Assessment (FSA)
1362 M. Fera, R. Macchiaroli / Safety Science 48 (2010) 13611368
The use of the geometrical mean for the collection of different
judgments is fundamental, because it has been demonstrated
(IMO, 2002) that its use minimizes the inconsistency of the com-
parison matrix C (see forward), for the reason that the unanimity
and homogeneity properties are respected. The unanimity prop-
erty states that, when all the experts give the same judgment x,
the resulting overall judgment should be x. The homogeneity prop-
erty states that when individuals give a judgement u times larger
than another, the resulting overall judgment should be u times lar-
ger too. A mathematical formulation of the unanimity and homo-
geneity properties is reported in (2) and (3)
f x; x; . . . ; x x 8 x 2 X 2
f ux
1
; ux
2
; . . . ; ux
n
uf x
1
; x
2
; . . . ; x
n
8 x; ux 2 X; u 2 R 3
Once the resulting overall judgments are computed, through Eq.
(1), they are inserted into a square matrix (nxn), named compari-
son matrix, C.
C D
1
D
2
. . . . . . D
n
D
1
D
2
. . .
. . .
D
n
j
11
j
12
. . . . . . j
1n
j
21
j
22
. . . . . . j
2n
. . . . . . . . . . . . . . .
. . . . . . . . . . . . . . .
j
n1
j
n2
. . . . . . j
nn
0
B
B
B
B
B
B
@
1
C
C
C
C
C
C
A
A fundamental condition to be respected for the applicability of
the AHP methodology is that the comparison matrix C is consis-
tent. We say that a matrix A = (a
ij
) is consistent if the transitivity
and symmetric properties are satised, as expressed in (4) and (5).
a
ij
a
jk
a
ik
where i; j; k 1; 2; . . . ; n 4
a
ij
a
ji
1 where i; j 1; 2; . . . ; n 5
To maximize the consistency index of matrix C, besides the fact
that elements with k = i always equal 1, the elements with k i
should respect the condition reported in (6).
j
ik

1
j
ki
6
In real applications, however, it is possible that relation (6) is
not satised. This implies that an inconsistency may occur. For
the correct applicability of the AHP methodology, it is important
that the inconsistency of the comparison matrix C is less than
10%, i.e., the number of times in which relations (4) are not veried
has to be less than 10%.
The ranking of the possible decisions D
i
, as stemming from the
judgments of experts, can be computed from the entries j
ik
of the
comparison matrix C. To each row, corresponding to a decision
D
i
, is assigned a priority index p
i
, computed as the ratio between
the sum of the entries of that row (
P
k
j
ki
) divided by the sum of
all entries in C (
P
k
P
i
j
ki
), as reported in (7).
p
i

X
k
j
ki
,
X
k
X
i
j
ki
7
4. The proposed risk assessment model
The proposed model is divided in three phases and each phase
is divided into steps, that involve, alternatively, methods like FME-
CA, SCEBRA, standard UNI 7249:2007 and AHP. In Table 3, we re-
port the methods used for each step.
The rst aims at the creation of the work team and the classi-
cation of major risks; this is achieved using the SceBRA and the
AHP techniques. In the second phase the risk assessment is focused
on the risk criticality calculation, and this is achieved using the
Italian UNI standard and the FMECA technique. The last phase
deals with the identication and classication of preventive and
protective actions to minimize the risks; this task is achieved using
again the AHP and some safety economic measurement tech-
niques. Refer to Fig. 1 for a schematic sketch of the proposed
model.
The SceBRA technique is mostly used in the management eld,
especially when an analysis of different development scenarios is
needed. Just in a few cases SceBRA has been used for the safety
risks analysis. In our model, it is used to overcome the problem
of the risks identication.
The literature reports some contributions that use FMECA to as-
sess safety problems. Indeed, in practice it is quite easy to nd in
the FMECA modules columns reserved to the maintenance activi-
ties safety. In turn, in our model the FMECA is just used as a refer-
ence to evaluate the criticality of each risk.
UNI 7249:2007 is an Italian standard that illustrates the calcu-
lation methods for the frequency and consequence indexes, start-
ing from the injuries data available in each rm.
AHP has been selected to reduce the subjectivity of steps 2 and
6. AHP permits to give relative judgements of relevance among dif-
ferent risks, not just using numerical values, but also with verbal
statements (indeed, a translation table from verbal statements to
numerical values is also present). Refer to former Section 3 for a
deeper introduction to that technique. It is important to note that
the choice of the AHP, instead of other structured methods such as
the DELPHI one, was due to the more reliable analysis of the AHP,
that is conducted using mathematical tools.
In the following part of the paper we analyse and describe in
better detail the seven steps of the model used to perform risk
assessment.
4.1. Phase 1 major risk identication
The rst step, i.e., team building, is very important, because it is
the main element to ensure an adequate reliability of the assess-
ment. Team composition could be deduced from the safety rm
organization, that is imposed, largely, by national safety laws.
Our will is to build a new assessment model, also respectful to
safety laws in force. The minimal team composition should be:
(i) the safety responsible, (ii) a work medicine expert and (iii) a
production worker expert.
The second step, i.e., risk identication, is carried out with the
application of the AHP technique. For each couple of risks, experts
will give a judgement of relative importance. Each risk is assessed
comparing itself with all the others; in other words, experts must
specify how much the analysed risk is relevant compared with all
the others. The relative importance judgement given by experts for
each risks couple are collected in a geometrical mean, which be-
comes an element of the general comparison matrix, used to quan-
tify priorities between all risks. The hierarchy used to determine
priorities between all possible rms risks is reported in Fig. 2.
Table 3
Methods used for each step.
Phase Step Description Method
1 1 Team work identication SceBRA
2 Major events identication SceBRAAHP
2 3 Frequencies calculation FMECAUNI 7249
4 Consequences calculation FMECAUNI7249
5 Criticality calculation FMECA
3 6 Improvement actions priorization AHP
7 Improvement action verifying Mixed techniques
M. Fera, R. Macchiaroli / Safety Science 48 (2010) 13611368 1363
4.2. Phase 2 risk assessment
Once the results of the second step, i.e., the risks priority, are
obtained, it is possible to proceed to the third and fourth steps.
Here the model proposes the calculation of the frequency and con-
sequence indexes, which are computed referring to Italian national
standard, UNI 7249:2007 (this standard is available also in English
as Statistics on occupational injuries). The equations used to cal-
culate both of them are reported in (8) and (9).
F
I
A
I
m
E
h
10
6
8
C
I
G
T

I
G
P

I
G
M
E
10
3
I
G
T
7500
P
g
100

7500 m
E
10
3
9
In (8),
I
A is the number of injuries causing an inability lasting
more than a day,
I
m is the number of deaths and E
h
is the worked
hours. In (9),
I
G
T
,
I
G
P
,
I
G
M
are respectively the off-work days due to
(i) a temporary injury, (ii) to an injury with permanent conse-
quences and (iii) to a death injury, and E is (iv) the total number
of workers employed in the specic work sector. All these data
are, normally, available in the rms injury registration book.
Please note that in the proposed procedure F and C are not an
estimate, possibly given by the risk auditor, of, respectively, the
probability of occurrence of the dangerous event and of the impor-
tance of the damage caused, as it usually occurs in typical risk
assessment procedures. In the proposed model F and C are simply
computed using historical data.
After this step, the procedure starts to implement the fth step,
i.e., the calculation of the general criticality index that integrates
the results obtained in previous steps. The equation used to calcu-
late the evaluation index is reported in (10).
I
k
F
k
C
k
p
k
DF C
F
k
C
k
p
k
F C
max
F C
min
10
In (10), F
k
and C
k
are, respectively, the frequency and the conse-
quence indexes for the kth risk analysed, as computed in steps 3
and 4, and p
k
is the priority index, as computed in step 2. So, again,
I
k
accounts for the importance of the kth risk, as it results from the
rms history. The second term of the sum has been introduced
to assess all risks that do not have a history, i.e., for those risks
for which it is impossible to determine the frequency and the con-
sequence indexes. It is important to notice how the second term
gives a more specic evaluation of the typical risks of a rm; in
fact, the p
k
index is calculated comparing each risk with the others
in specic working environment, while the difference D(F C) can
be seen as a reference scale, that gives an idea of the overall risk
level of a rm.
Willing to explain why the method proposes to evaluate the in-
dex I
k
as in expression (10), we could say that the attempt was to
introduce an evaluation method able to take into account, fromone
hand, the history of a rm, thus accounting not only for occurred
injuries (through the evaluation of C) but also for not occurred ones
(if F has a low value, that could mean also that prevention and pro-
tection measures in place might have been effective, despite of the
possible severity of the damage), from the other hand, the judg-
ments of experts, ltered through a method as AHP, as in tradi-
tional risk assessment schemes. In other words, we recognized
that relying only on experts traditional assessment methods could
lead to relying too much on their experience and not to pay enough
attention to the specic rm point of view, thus leading to empha-
size too much the consequences of an accidents and to underesti-
mate both the probability of occurrence and the prevention and
protection measures already in place.
Let us give an example. In real cases it could happen that a spe-
cic hazard has never lead to the occurrence of an accident: think,
1)Team work
identification
2) Major events
identification
S
C
E
B
R
A
3) Frequencies
calculation
4) Consequences
calculation
5) Criticality
calculation
F
M
E
C
A
-
U
N
I
F
M
E
C
A
S
C
E
B
R
A
-
A
H
P
6) Improvement
actions priorization
A
H
P
7) Improvement
action verifying
M
I
X
Phase 1 Phase 3 Phase 2
Fig. 1. Assessment model.
Fig. 2. Risks hierarchy.
in example, to a re in a paper mill plant. When evaluating the re
risk using our method, since the product F C equals 0, it might
happen that the proposed method evaluates it as less relevant
compared to other risks; an expert, instead, could see the re risk
as the most relevant risk, simply because of the serious conse-
quences of re accident occurrence. So, which is the right way to
watch to the problem? In our opinion, clearly, the right way to as-
sess the risk is the one proposed here. In fact, the gravity of the re
risk is accounted for with the second term of Eq. (10), while, if no
accident happened in the history of a rm, this means that the cor-
responding safety level is acceptable and, specically, the preven-
tion actions in place are effective. A conclusion which we might
draw from this example is that, if the prevention and protection
measure in place in a rm produced a history with no accidents,
this has to force the attention of the auditor not only towards risks
with major consequences but also towards other risks, more rele-
vant in that rm and, as retrievable from the rms safety history,
not properly managed in the past.
Another example, quite different, regards a risk that occurred in
one of the test cases presented afterwards in this paper. Let us con-
sider the risk stemming from the exposure to severe indoor climate
conditions in a service company dealing with logistics of owers. A
traditional approach could lead to underestimate indoor climate
risk when compared with other risk, like in example mechanical
risk, possibly because of their higher consequences. With our ap-
proach, the importance of the consequences of such risks is taken
into account through the second term of Eq. (5), but meanwhile
the analysis of the rms history leads to a relevant value of factor
F for the indoor climate risk (if that risk factor actually caused trou-
bles to employees health) in the rst term of the equation, thus
allowing to balance different factors and to assess that risk prop-
erly. In other words, in this case, what the proposed method is able
to stress and take account for is the actual occurrence of a damage
and/or an injury and not only its probability, as estimated by an
expert.
Willing to draw up some conclusions, we might say that the
proposed method denes a procedure to reduce the impact of a
wrong risk perception by experts. In particular:
the criticality index for a risk that has never been happened,
is composed by a term that is zero (i.e., the rst term in Eq.
(10)) and by a term composed by the relevance judgement
of the experts, derived by the AHP method application
(i.e., p
k
) and by an index that is specic to the rm analysed
in the assessment (i.e., D(F C)); the result is a mitigation of
the possible overemphasis resulting from a too high estima-
tion of the risks consequences that also takes into account
prevention and protection measures in place, and
the criticality index for a risk that occurred often is com-
posed by a term that properly takes into account the fre-
quency of occurrence (i.e., factor F in the rst term of Eq.
(10)) and by a term composed by the relevance judgement
of the experts, as before; the result is a mitigation of the
possible underestimation of the risk, that takes into account
the actual occurrence frequency of the corresponding dam-
ages and/or injuries.
Finally, let us propose a comment on how to apply the method
when the safety auditor is analysing a start-up company; in this
case the rst term of Eq. (10) is equal to zero, not because the spe-
cic risk never lead to accidents, but because the rm has not got a
history. This problem could be overcome using external statistics
referred to the specic sector of the start-up rm. For example,
in Italy the public work injuries insurance agency (INAIL) produces
the summary of the frequencies and consequence for the different
operative sectors each year. So, using these statistics, the method
could be used also for the start-up rms. It must be claimed, how-
ever, that the best performance of the proposed method is actually
achieved in rms with a safety history.
4.3. Phase 3 improvement actions
Once a criticality has been dened for all risks, the model pro-
ceeds with the sixth step, i.e., the identication of preventive and
protective measures used, respectively, to reduce the frequency
of occurrence and the consequences of the dangerous event. This
step is implemented through a team meeting, as dened in step
1, and trough a new application of AHP. For each risk, the experts
will dene some actions, and afterwards they will express their rel-
ative judgements between the proposed actions. The calculation
procedure to obtain the actions priorities is the same of step 2.
The improving actions hierarchy is shown in Fig. 3.
The innovation of the method for the identication of preven-
tion and protection actions is centered on the use of AHP, that per-
mits to reduce inconsistencies of the decisions regarding
implementation priorities for the different corrective actions
decided for each risks. In other words, when dening priorities
among corrective actions, it may happen that some inconsistency
occurs or, more simply, that their scheduling does not respond
effectively to actual needs. The application of AHP allows to reduce
this circumstance, simply because the AHP mathematical approach
is able to minimize inconsistencies among relative priority judg-
ments given by experts to corrective actions.
Once prevention and protection actions, as dened in step 6, are
implemented, it is necessary to evaluate their effectiveness. This is
the goal of step 7. To this aim we propose the use of an index
named DOE, which has been created by the US Department Of En-
ergy, and whose denition is reported in (11).
DOE
10
2
10
6
D510
5
T 210
3
LWC10
3
WDL410
2
WDLR210
3
NFC
E
h
11
In (11), D is the number of deaths, T is the number of injuries
with total disability, LWC is the number of accidents with an injury,
WDL is the number of work absence days, WDLR is the number of
days in which a production sector has to work in a limited mode,
NFC is the number of near miss and E
h
is the number of total work-
ing hours. Using this index over an appropriate time horizon, it is
possible to measure the safety system improvement. If the index
shows an increase from a period to another, i.e., the difference of
the values it assumes over two periods is positive or equals zero,
Fig. 3. Improving actions hierarchy.
it means that the assessment and the improvement actions were
not adequate, thus another implementation of the procedure is
required.
Notice how the application of the method nds its natural best
performance when it is applied in a continuous improvement
framework, such as the Deming wheel (Fig. 4), i.e., where there is
a continuous improvement led by the cyclic application of phases:
(i) plan, (ii) do, (iii) check, (iv) act. This is typical of all Management
Systems that pursue continuous improvement strategies, like
Quality or Safety Management Systems planned as in ISO EN
9001:2008 or OSHAS 18000.
5. The experimental campaign
To test the performance of the proposed method and its ability
to easily and properly assess risks and, consequently, to identify
effective prevention and protection measures, an experimental
campaign was performed in three enterprises classied as SMEs.
The enterprises belong to two different sectors, the steel work
industry and the logistic services; in particular, two belong to the
rst sector and one to the other one.
Before describing and commenting the results, let us explain
the method we used to validate the proposed model. The results
of the experiments, as stemming from the application of the pro-
posed method to the three rms, were compared with:
the results of traditional methods used to assess safety at work
in these rms and
the risk classication, as calculated from the injuries statistics
available for the industrial sector who they belong to.
The reason for not relying solely on rms available data is that
they could suffer from underreporting (think about missed acci-
dents) and limited exposure (so that real hazards may not have
materialized yet and hence not being represented in the statistics,
but may still pose a signicant risk). The use aggregated data, spe-
cic of an industrial sector, rather than data for individual rms,
can possibly give a better, or at least a wider, picture of the risk
than company-specic data. Still, the use of company-specic data
helps in analysing and underlining special features which might be
present within particular rms.
The effectiveness of the proposed method was assessed through
an index named reliability index computed as the distance be-
tween the ranking of each risk, available from the injuries registry
and from the national statistics for the sector, and the ranking
resulting from the application of the old and new methods; each
position in the ranking equals one distance unit; so, the best per-
formance is achieved if the distance index equals zero, while the
more the index grows, the more we can say that the proposed
method achieves misleading results compared to the actual risk
classication.
The rst experiment was conducted in a steel working factory.
It is an assembly line, operating on 3 shifts for 24 h. The working
activities include machines set-up, feeding of material to the ma-
chines and machine control. In the production line workers also
manipulate chemical products, as ammable or noxious
substances.
All the risks were identied and assessed using the new meth-
od. The criticality indexes, for the production line analysed, are
shown in Table 4.
Fig. 4. The Deming wheel.
Table 4
Criticality index for the risks in the assembly line analysed.
Risk Criticality indexes
Mechanical 33,64
Knife parts contact 10,14
Material in movement contact 6,69
Electric 6,38
Noise 4,24
Fire 1,32
Vibrations 1,11
Table 5
Old and new assessment model risk prioritization compared with real data for rst experiment.
New assessment method Specic rm statistics Industrial sector national statistics Old assessment method
Mechanical Mechanical Material in movement contact Noise
Knife parts contact Knife parts contact Knife parts contact Fire
Material in movement contact Material in movement contact Mechanical Mechanical
Electric Electric Vibrations Electric
Noise Vibrations Noise Vibrations
Fire Fire Fire Material in movement contacts
Vibrations Noise Chemical Knife parts contact
Chemical Chemical Electric Chemical
Table 6
Reliability indexes for the assessment method analysed.
Distances New assessment
method
Old assessment
method
Compared to specic rm
statics
4 21
Compared to national
statistics
12 25
Table 7
Criticality indexes for the second experiment.
Risks Criticality indexes
Mechanical 25.12
Manual handling contact 6.79
Knife contacts 3.90
Noise 2.44
Electrical 1.76
Fire 1.03
Mechanical handling contact 0.74
Vibrations 0.62
Chemical 0.39
Micro-climate 0.31
Explosions 0.27
Table 5 reports the risk priority ranking for respectively, the
proposed assessment model, the actual data available in the spe-
cic rm, the statistics data from the industrial sector as reported
by the Italian Health and Safety Insurance Institute (INAIL) and the
traditional assessment model used in the rm so far. As shown, the
new model matches actual data more often than the old assess-
ment model. In Table 6, the reliability indexes are reported.
The second experiment was conducted in another steel working
factory, whose typical operations are quite different from the rst
example, in the sense that there are no continuous operations on a
24 h time basis. Operations include cutting, welding and hot-work-
ing on metal sheets. So the job exposes the workers to several risks
such mechanical, chemical, noise, etc.
As in the previous test case, Table 7 reports the criticality in-
dexes as calculated with the proposed method, Table 8 compares
the risk priority ranking in the four possible cases, while Table 9 re-
ports the reliability indexes for the two methods.
The third application of the proposed method occurred in a lo-
gistic services rm, a ower logistic operator. The process includes
receiving, storing and expediting ower batches. Workers are ex-
posed to risks like micro-climate, ergonomic, mechanical move-
ment, etc. The exposure to the micro-climate risks is due to the
fact that the owers need to be stored in a cold-store, where all
handling operations are performed.
As in previous cases Tables 1012 report, respectively, the crit-
icality indexes, the risk priorities and the reliability indexes for this
last experiment.
As a general comment, the proposed model actually shows a
remarkable improvement in terms of what we dened reliability
of the safety assessment method. The model achieves a reliability
value considerably better than traditional methods when the index
is compared with the data from the statistics of the specic rm.
On the other hand, when we compare the results with the national
statistics for the specic sector to which the enterprises belong, the
methods improvement, on average, is less than 50% of the rst
result.
The high correspondence between risk priorities as identied by
the proposed method and as retrievable by the actual injuries sta-
tistics for the specic rms, is due, possibly, to the fact that the
proposed method is combining some subjective elements, as the
experts contribution, to objective elements, as the UNI 7249,
which is based on the same framework used for the injuries real
statistics calculation. This element is very important to understand
Table 8
Old and new assessment model risk prioritization compared with real data for second experiment.
Mechanical Mechanical Manual handling contact Mechanical
Manual handling contact Manual handling contact Knife parts contact Noise
Knife contacts Knife contacts Mechanical Knife contacts
Noise Mechanical handling contact Vibrations Chemical
Electric Electrical Electric Manual handling contact
Fire Fire Noise Mechanical handling contact
Mechanical handling contact Noise Fire Electric
Vibrations Vibrations Mechanical handling contact Vibrations
Chemical Chemical Chemical Fire
Micro-climate Micro-climate Micro-climate Micro-climate
Explosions Explosions Explosions Explosions
Table 9
method
Old assessment
method
statistics
6 20
Compared to national sector
statistics
12 26
Table 10
Criticality indexes for the third experiment.
Risks Criticality indexes
Micro-climate 10
Manual handling 7.5
Mechanical handling 1.7
Mechanical 0.62
Chemical 0.47
Noise 0.43
Electrical 0.39
Fire 0.24
Table 11
Old and new assessment model risk prioritization compared with real data for third experiment.
Micro-climate Micro-climate Mechanical handling Mechanical
Manual handling Manual handling Micro-climate Micro-climate
Mechanical handling Mechanical handling Manual handling Manual handling
Mechanical Mechanical Noise Mechanical handling
Chemical Chemical Mechanical Chemical
Noise Noise Chemical Noise
Electrical Electrical Fire Electrical
Fire Fire Electrical Fire
Table 12
method
Old assessment
method
statistics
0 5
Compared to national sector
statistics
10 12
how much the new method tries to create a more realistic analysis
of the safety condition, without neglecting the experts point of
view, and thus giving the possibility to assess also the elements
not otherwise classiable with objective methods.
In Table 13, we report a summary of the performance indexes in
the experiments. It is possible to notice how the models perfor-
mance in terms of reliability shows an average increase of 84% if
its reliability is compared with the specic rm ranking and of
41% if it is compared with the national statistics. It is also worth
to note how in the third experiment the improvement shown by
our method in the second comparison decreases. The closest indus-
trial sector found for this experiment was the whole logistic and
transportation one, whose scope is very wide and who, thus, has
a very large number of job types; accordingly in our opinion
this sector is not exactly reecting the risk characteristics of the
analysed rm.
6. Conclusions
Starting from the awful statistics of the safety at work, as they
result in the EU and worldwide, in this paper we analysed the state
of the art in risk assessment methods applied in small and medium
enterprises (SMEs) and we found a lack of models applying both
quantitative and qualitative methods. So, the attempt was to de-
velop a model able to reduce the uncertainty that subjective mod-
els typically offer and the computational complexity that objective
and quantitative models normally include (with the related costs
and time consumption), thus representing a method that, making
use of the same amount of effort, is able to achieve better and more
reliable results. The proposed model therefore merged known
quantitative models, like the ones using frequency and conse-
quence indexes, with typical subjective models, such as the AHP
models. The proposed approach, through the use of AHP, allows
to assess also risks related to aspects and dangers which have no
history, and for which necessarily a subjective approach applies.
The application of the proposed model has shown a good per-
formance in terms of risk assessment reliability: by this we mean
that the risk prioritization resulting from the proposed risk assess-
ment model is better than the one resulting from traditional meth-
ods, when compared with statistic data from the specic rm, as
retrieved from the injuries and accident register book, and with
the national industrial sector, as retrieved from the national indus-
trial sector statistic survey on injuries and accidents in the Italian
rms performed by INAIL.
Next steps in the research will deal with the validation of the
method for the identication and prioritization of the improve-
ment actions and the application and validation of the model in
other industry sectors.
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Experiments Distances national sector
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Distances specic rm
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1 52 81
2 54 70
3 17 100
Mean 41 84
A semi-quantitative assessment of occupational risks using bow-tie representation
Celeste Jacinto
a,b,
*
, Cristina Silva
c
a
Department of Mechanical and Industrial Engineering, Faculty of Science and Technology, Universidade Nova de, Lisboa, Campus de Caparica, 2829-516 Caparica, Portugal
b
Safety, Reliability and Maintenance Group of CENTEC, Technical University of Lisbon, Instituto Superior Tcnico, Av. Rovisco Pais, 1049-001 Lisboa, Portugal
c
Arsenal do Alfeite, Alfeite, 2810-001 Almada, Portugal
a r t i c l e i n f o
Article history:
Received 16 January 2009
Received in revised form 3 August 2009
Accepted 30 August 2009
Keywords:
Safety at work
Risk assessment methods
Bow-tie diagrams
Occupational safety
Eurostat variables
a b s t r a c t
This work proposes a semi-quantitative risk assessment methodology, which was applied and tested in
the Ship Building Industry. It covers a wide range of risks related to occupational accidents in a shipbuild-
ing yard environment, more specically at Arsenal do Alfeite, a large shipyard in Portugal. The initial
qualitative analysis focuses on the bow-tie diagram technique but it also integrates concepts and classi-
cations schemes dened by the Eurostat within the European Statistics on Accidents at Work (ESAW)
Project. The structure of the diagram enables the identication of the relevant accidents causal pathways
and their consequences at the same time as it identies the existing or needed safety barriers. In what
concerns the semi-quantitative assessment, the accident risk level and acceptance criteria were estab-
lished through a scoring system, using national data on accident statistics for the sub-sector: Ship Building
& Repairing (code NACE 35.1). The statistical data was supplied by GEP (the Ofce of Strategy & Planning
of the Portuguese Ministry of Labour & Social Solidarity). The authors present and discuss a specic case
study, in the shipyards technological area of surface treatment and protection, to demonstrate the meth-
ods applicability and usefulness.
2009 Elsevier Ltd. All rights reserved.
1. Introduction
The original bow-tie model was developed for application in hi-
tech industries, for the probabilistic assessment of risks of major
industrial accidents. However, as with many other assessment
techniques, its use is quickly spreading to the eld of occupational
safety. A recent special issue of Safety Science (Goossens et al.,
2008), for instance, gives full evidence of this trend and provides
insight in the development of an Occupational Risk Model (ORM),
launched under the auspices of the Dutch Authorities.
Despite this breakthrough in the quantitative assessment of
occupational risks, the bow-tie probabilistic feature is less likely
applicable or viable in individual organisations, in which the his-
toric accident information is not enough to derive data for the
probabilistic assessments. On the other hand, the diagram itself
and the philosophy behind its conguration appears to be an
attractive tool for risk identication and qualitative analysis: not
only the diagram depicts the possible pathways between the haz-
ards and the accident (the central critical event), but also it com-
pels the analyst to differentiate clearly between preventive and
protective barriers. The latter characteristic is of great value to sup-
port decision-making, since it helps prioritising safety measures.
A way out from the lack of probabilistic data is to combine the
qualitative feature of the diagram with an (also qualitative) assess-
ment of risk through a classical risk-matrix approach. This is a fea-
sible solution already offered in commercially available software
packages (e.g.: BAT
, Risk Shield
or BowTie Pro
). However, in
most applications, the problem of inherent subjectivity of the ma-
trix remains. The aim of this research work, though, is twofold: (1)
to ascertain to what extent the bow-tie diagram would be success-
fully applied to occupational risks, in individual organisations, by
their own people and (2) to explore a semi-quantitative methodol-
ogy for grading the risks and establishing the risk level. The second
issue, in particular, constitutes the innovating contribution of this
work, as it gives a simpler alternative to the probabilistic approach
whilst still keeping the virtue of being based on real accident fre-
quency data and objective criteria.
To demonstrate the proposed methodology, this paper de-
scribes an application case in a large shipyard, called Arsenal do
Alfeite (AA), whose main activity is to build and repair ships,
mainly for the Portuguese Navy. From now on, this organisation
will simply be referred to as AA Shipyard.
2. Background literature on the bow-tie model
Although the majority of risk assessment techniques have been
designed for risks arising from high-tech systems, Harms-Ringdahl
0925-7535/$ - see front matter 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ssci.2009.08.008
* Corresponding author. Address: Department of Mechanical and Industrial
Engineering, Faculty of Science and Technology, FCT/UNL, Campus de Caparica,
2829-516 Caparica, Portugal. Tel.: +351 21 294 8567; fax: +351 21 294 8546.
E-mail addresses: mcj@fct.unl.pt (C. Jacinto), cristinanevescabral@hotmail.com
(C. Silva).
Safety Science 48 (2010) 973979
Contents lists available at ScienceDirect
Safety Science
j our nal homepage: www. el sevi er . com/ l ocat e/ ssci
(2001) demonstrates that some of these methods have proven to
be useful and adequate to assess all kinds of risk, including those
associated with occupational hazards. This seems to be the case
with the so-called bow-tie approach as well.
On the turn of the millennium, the Shells Group developed a
new approach under the name of Hazard, Effect and Management
Process (HEMP); this was known internally as the bow-tie dia-
gram (Zuijderduijn, 1999). This concept gained popularity, as it of-
fers a good overview of the different accident scenarios under
analysis. Basically, the bow-tie can be considered as an approach
that has both proactive and reactive elements and that systemati-
cally works through the hazard and its management. Indeed, all
the causes and consequences of an accident are clearly depicted
in the diagrams. Moreover, the bow-tie seems particularly useful
to represent the inuence of safety systems (and barriers) on the
progression of accident scenarios. Safety systems, either technical
or organizational elements, can be placed in the two main
branches of the diagram. The bow-tie model is essentially a prob-
abilistic technique, but in time it has developed in different ver-
sions, depending on the system under analysis. A well-known
simplied representation is that in Fig. 1.
In its traditional representation the left-hand side includes a list
of potential hazards leading, through different pathways, to a spe-
cic top critical event or accident type, whilst the right-hand side
includes the different consequences of such event. The left side can
include a formal fault tree in which the different branches identify
the possible causes of the critical event (i.e., all the possible links
between the hazards and the accident type).
The right side of the diagram, on the other hand, uses the event
tree philosophy to identify the possible consequences. Between the
hazards and the top event, and between the latter and the nal
consequences, the safety barriers in place are also taken into ac-
count. An evaluation of barrier performance (e.g.: response time,
efciency, and level of condence) can be achieved with this ap-
proach. An important and useful feature is that this barrier analysis
helps to identify missing or ill-designed barriers, which is a key-is-
sue in risk management. The work of Trbojevic (2001), Delvosalle
et al. (2003) and Kurowicka et al. (2006), for instance, give a de-
tailed account of the bow-tie structure and the barrier functions
associated with it.
On the other hand, Delvosalle et al. (2003) and Salvi and Deb-
ray (2006), provide evidence of another noteworthy development
around 2002, within the Accidental Risk Assessment Methodol-
ogy for Industries in the framework of Seveso-II Directive (ARA-
MIS) Project . A new integrated risk assessment methodology
was created (Delvosalle et al., 2006; Dianous and Fivez, 2006),
by combining the strengths of different methods currently used
in the European Countries. This new methodology, under the
name of Methodology for the Identication of Major Accident
Hazards (MIMAH), is supported by the bow-tie approach and
the assessment of safety barriers. However, this integrated ap-
proach focuses on industries within the framework of Seveso-II
directive, i.e., on major industrial accidents, leaving aside the
occupational accidents.
More recently, however, the bow-tie model has entered the
eld of occupational safety, through the European Workgroup for
development of the Occupational Risk Model (WORM), which
started with the aim of decreasing by 1015% the occupational
accident rate in the Netherlands (Hale et al., 2005). This research
workgroup uses the bow-tie approach to quantify risks of occupa-
tional accidents with the purpose of introducing a risk-based
thinking into occupational safety and by simulating scenarios for
a wide variety of common accidents, allowing the prioritisation
of preventive strategies. The WORM Project is still ongoing but it
has already produced ample evidence of progress by the work of,
for instance, Papazoglou and Ale (2007); Ale et al. (2008); Aneziris
et al. (2008) and Bellamy et al. (2008).
The quantication of the bow-tie diagram is a complex task: it
not only requires reliable data on the frequency of all events, but
the failure probabilities of the barriers need to be known as well.
This type of assessment also calls for the involvement of highly
specialised people from different expertise areas. For all these rea-
sons, it is unlikely that individual enterprises will be able to apply
the model in this way. Despite this, the diagram, per se, constitutes
an attractive basis to support qualitative analysis.
From all the above it becomes apparent that the bow-tie ap-
proach represents a step forward in the current state of the art con-
cerning the management of risks, including those associated with
occupational safety. This is the context in which the authors equa-
ted the use of the (qualitative) bow-tie diagram in combination
with a matrix approach, based on accident statistics of the activity
under analysis.
3. The methodology applied in the AA Shipyard
The methodology described here uses accident data of the Ship-
building Industry and it will be demonstrated through an applica-
tion case in this particular activity sector.
3.1. The working context and the organisations main features
Since the historical accident data in the AA Shipyard is not suf-
cient to allow probabilistic assessments, the quantication fea-
ture of the original bow-tie model is not used in this work. In
this case the aim was to explore the applicability of the diagram
in critical activities in this large shipbuilding yard, within a semi-
quantitative assessment adapted to their own reality.
The AA Shipyard employs around 1200 workers and its main
activity consists of repair works and maintenance of ships for the
Portuguese Navy, although they also have non-military clients.
The organisation holds a Quality Management System certied
ISO 9001:2000 and a structure of Internal H&S Services; the latter
comprises two main branches: the Occupational Medicine Service
and the Division of Safety & Health. The organisations safety reg-
ulations and procedures are compiled and published in the Arse-
nal Safety Book Safe Work (Arsenal do Alfeite, 2003), which is
also available through their own intra-network. The risk assess-
ment procedure currently in use for occupational risks is a classical
all-embracing approach, which combines Energy Analysis with
Task Analysis, and uses a risk-matrix for grading the risks. The cri-
teria in the matrix, however, are rather vague and subjective.
H
A
Z
A
R
D
S
C
O
N
S
E
Q
U
N
C
I
A
S
Barreiras de segurana
Evento
Safety Barriers
CRITICAL
EVENT
Fault Tree Event Tree
C
O
N
S
E
Q
U
E
N
C
E
S
Fig. 1. A simplied bow-tie representation (Dianous and Fivez, 2006, p. 221;
Delvosalle et al., 2006, p. 201).
974 C. Jacinto, C. Silva / Safety Science 48 (2010) 973979
3.2. The methodology semi-quantitative bow-tie for accidents at
work (SQ-BAT)
The acronym SQ-BAT was established at a certain point, to dif-
ferentiate this new method under trial from the current procedure
in AA Shipyard, which does not have a specic name. Overall, the
methodology applied can be described in a two-step process, as de-
picted in Fig. 2.
1
3.2.1. Qualitative analysis rst step
This rst step uses the bow-tie diagram as a qualitative tool for
identifying the pertinent causes and consequences of the accident
type under analysis; it also pinpoints the relevant prevention and
protection barriers for eliminating, reducing or attenuating the
effects of such accident risk. Before initiating the diagrams, the fol-
lowing preliminary tasks were carried out to collect indispensable
and valuable information:
re-analysis of previous accidents (period 20012006 inclusive),
scrutiny of Safety Audit reports and other Management System
documentation,
establishment of a baseline checklist (pinpointing hazards and
hazardous conditions already known or perceived by the
authors),
interviews with the workers and their supervisors to bring out
their points of view and experience feedback, and
direct observations of the workplace.
The diagrams were produced with the information collected
above; this involved an iterative process since there was a need
to re-check and conrm certain details before reaching the nal
draw. The type of accident (critical event) was categorised by the
variable contact-mode of injury. This automatically means that,
the risk analysis of each single task implies the construction of
eight individual diagrams, as the variable contact has eight dif-
ferent modalities (or categories) in its classication scheme (Euro-
stat, 2001). The variable deviation was also used to label the
deviating events immediately preceding the contact on the centre
of each diagram. This helped to compare the various pathways
actually identied in the diagrams with the statistical information
available for the pairs contact deviation. After the qualitative
analysis based on the diagram is completed, the second step takes
place, i.e., the assessment of accident risk.
3.2.2. Semi-quantitative assessment second step
To enable the link between the diagrams and the semi-quanti-
tative assessment, the authors developed a scoring system based
on a specic subset of national accident statistics, aligned with
the ESAW harmonised variables (Eurostat, 2001). This statistical
data is used to score, objectively, the likelihood of occurrence
and the potential seriousness of each modality of accident. The
resulting scores are then applied to a risk-matrix (similar to that
of BS 8800, 2004) for obtaining the risk level. The aim of this
two-step approach is to reduce subjectivity, since the scoring sys-
tems used are based on realistic accident frequencies and days lost
for each accident type.
To carry out the above process, the ESAW variables considered
were contact and days lost. The semi-quantitative procedure
for ranking the accident risk level uses a 4 5 risk-matrix, with
ve levels of risk. The criteria for scoring likelihood and poten-
tial seriousness were derived from the national statistics of the
activity sector 35.1 building and repairing of ships and boats,
2
used
here as the reference sector. The likelihood of occurrence was
ranked through the frequency distribution of the variable contact,
whereas the potential seriousness was established by crossing the
data of the variables contact days lost.
4. Case study and results
In the AA Shipyard accident history, the production area posing
higher concerns is the Treatment and Protection of Surfaces or
TPS-Area. This technological area deals, essentially, with special
coating schemes and it comprises three main production processes
and facilities: steel-blasting, electroplating and dry dock airless
painting. This paper discusses the proposed methodology applied
to a particular type of accident in the steel-blasting process.
Collect information
on site
Scope definition:
TPS-Area
Qualitative analysis
Mapping the accident scenarios
1 task = 8 diagrams
Barreirasdeseguran a
Evento
Barriers
CRITICAL
EVENT
Risk Evaluation / Risk Level
Matrix approach
Criteria for likelihood & seriousness
Likelihood of critical event
Frequency distribution of variable
Contact
Severity of Harm
8 Accident pyramids to score
the potential for serious injuries
(days lost)
Accident typology
AA-TPS (data 2001-2006, N=52)
Sub-Sector 35.1 (national data
2005, N=1078)
O
U
T
C
O
M
E
H
A
Z
A
R
D
S
Collect information
on site
Scope definition:
TPS-Area
Qualitative analysis
Mapping the accident scenarios
1 task = 8 diagrams
Barreirasdeseguran a
Evento
Barriers
CRITICAL
EVENT
Risk Evaluation / Risk Level
Matrix approach
Criteria for likelihood & seriousness
Frequency distribution of variable
Contact
Severity of Harm
8 Accident pyramids to score
the potential for serious injuries
(days lost)
Accident typology
AA-TPS (data 2001-2006, N=52)
Sub-Sector 35.1 (national data
2005, N=1078)
O
U
T
C
O
M
E
H
A
Z
A
R
D
S
Fig. 2. Overview of the SQ-BAT methodology.
1
Work in Portuguese translates as Trabalho, hence the nal T in the acronym.
2
Classication NACE 4 in the ESAW system.
C. Jacinto, C. Silva / Safety Science 48 (2010) 973979 975
4.1. Risk analysis through the bow-tie diagram
The steel-blasting task is carried out in a blasting chamber and
it needs to be done manually by skilled operators, since the metal
parts (or pieces) to pickle have a very irregular shape and need to
be turned over more than once in the process. Fig. 3 illustrates this
working process. The pieces enter the chamber on the top of open
wagons on rails and the chamber can accommodate three pieces at
a time. The analysis of this task has produced eight diagrams, some
more complex than others, but each portraying the risk situation of
a specic type of accident, depending on the modality of contact in
the centre.
Fig. 4 shows the diagram obtained for Contact 40 (being struck
by object in motion, collision with). This modality is also the most
frequent type of accident in both the shipyards TPS-Area and the
Portuguese accident statistics of the whole sector 35.1 (building
and repairing of ships and boats).
The gure shows the relevant features concerning this particu-
lar accident risk. To summarise, one can see that there are at least
three main pathways leading to the critical event. This contact may
occur either by projection of steel particles under pressure, or by
the fall of a piece/component. The worker being struck by steel
particles is the most frequent occurrence and it can be triggered
by two main categories of deviation: the worker losing control of
the hose and jet direction or by emission of particles (inherent to
the process, but aggravated by failure of the hose or variations in
the pressure). The second possibility is the worker being struck
by a falling piece and this is more likely to occur when the worker
is turning over the piece. The dotted labels D20, D30 and D40 on
the diagram indicate the code of the main deviations identied
and the arrows indicate the possible paths between these devia-
tions (immediate causes) and the hazards/hazardous conditions
behind them. This left side of the diagram also identies the most
pertinent prevention barriers. Of these, some were already in place
and seemed reasonably adequate, whilst others were either miss-
ing or notoriously insufcient. In the aftermath of this analysis a
set of oor grids have already been replaced and the ventilation
and illumination levels have been improved. Two safety measures
were scheduled for further discussion, as they need more careful
consideration: (1) establishing a new procedure for hiring external
operators, who need to be certied and (2) redesigning the cur-
rent training plan, which needs to be more behavioural-driven. In
certain cases, the role of the supervisor and the level of supervision
also need improvement, but these are currently being equated to-
gether with the training strategy for supervisors.
The right side of the diagram (Fig. 4) is less detailed as the con-
sequence of any occurrence is always a personal injury, although
the degree of harm varies. This side shows, essentially, the factors
inuencing the seriousness and the barriers needed for protection
and emergency action. Of these, the main concern is to implement
a faster shutdown system actuated from inside the chamber (the
current one is only triggered from the outside).
Another possible improvement is to extend the information in
the workers ID card: currently it has the persons identication
and all emergency telephone numbers. A way forward is to include
the persons blood type and any known allergies (including allergic
reactions to medical drugs).
4.2. The accident prole in the AA Shipyard and in the whole activity
sector
Ideally, the estimation of accident risks in the particular task
analysed above should be based on accumulated real data from
the AA Shipyard, but the number of accidents and incidents in the
steel-blasting process has been low over the years. Even when con-
sidering the whole TPS-Area, which already comprises several pro-
cesses and a variety of tasks, the registers of six consecutive years
(20012006 inclusive) reveal no more than 52 accidents at work;
most were low injury cases and none was fatal. Given this limita-
tion with accident data, the authors opted for using the whole sec-
tor 35.1 as the reference dataset. Under the circumstances, this
seems to be a more robust starting point for establishing the risk
assessment criteria. The main indicators for the year 2005 are
those summarised in Table 1.
Despite the limitations discussed above, the accident proles of
the two datasets were compared (Fig. 5) to establish how the dis-
tribution of the variable contact-mode of injury (i.e., type of acci-
dent) in the TPS-Area ts within the corresponding distribution of
the whole sector.
Overall, the gure shows considerable similarities between the
two distributions, and it appears acceptable using the whole sector
as a reference. The Top-2 modalities of accident are the same and
are far more frequent than the rest, although there are differences
in their relative frequencies. When considered together, categories
C40 and C70 represent more than 50% of all accidents in this activ-
ity and the category C40 (struck by object in motion) is indisputably
the prevailing type of accident in both cases.
In the next section, the frequency distribution of the reference
sector will be used as an indicator to categorise and to score the
likelihood of occurrence of the critical events in the bow-tie dia-
grams (i.e., to categorise all eight types of accident). The distribu-
tion of the variable deviation was also scrutinised, together
with the cross-comparison of deviation contact (D C). In
the latter case, the purpose was essentially to verify which pairs
of modalities (Di Cj) were more relevant; this information was
then used to check each diagram for completeness, i.e., to make
sure that relevant deviation types had not been forgotten in the
applicable diagram.
4.3. The scoring system used for the assessment of accident risks
Having characterised the accident prole in this activity, and
established the frequency of each type of accident (critical event),
the next step was to explore a way of estimating the risk level as
objectively as possible and based on real accident data. A 4 5 Fig. 3. Steel-blasting task.
risk-matrix, with ve levels of risk, was established as shown in Ta-
ble 2.
The dimension likelihood of occurrence was categorised into four
classes of frequency, for which the criteria and scoring system is
shown in the table.
On the other hand, the dimension potential seriousness was
scored into ve classes, ranging from slightly harmful to fatal
injury, as is also given in the table. In this case, the harmonised
variable days lost was used to categorise the level of seriousness,
through the construction of accident pyramids, which are also
structured in ve levels.
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Fig. 4. The bow-tie diagram for Contact 40 (being struck by object in motion, collision with) in the steel-blasting task.
Table 1
Relevant indicators in sector 35.1 (building and repairing of ships and boats).
Indicators (activity sector 35.1) Year 2005
a
Number of fatal accidents 0
Number of non-fatal accidents
b
1078
Days lost
b
(total number) 18,407
Average seriousness (mean days lost/accident) 17
a
Reference year of data. In Portugal, this was the rst year using a 3-digits level
for coding the variable economic activity of the employer. Only 2005 data was
available when this study was made.
b
It must be pointed out that these non-fatal gures are not directly comparable
to the EU harmonised statistics, as the Portuguese recording system accounts for all
accidents, regardless the number of lost (0+ days).
(a) AA Shipyard (TPS Area) (N=52) (b) National level, whole Sector 35.1 (N=1 078)
Contact Mode of Injury; coding (Eurostat, 2001)
10. Contact with electrical voltage, temperature, hazardous subst.
20. Drowned, buried, enveloped
30. Horizontal or vertical impact with/ against a stationary object
(the victim is in motion)
40. Struck by object in motion, collision with
50. Contact with sharp, pointed, rough, coarse Mat. Agent
60. Trapped, crushed, etc.
70. Physical or mental stress
80. Bite, kick, etc. (by animal or human)
99. Other Contacts - Modes of Injury not listed above
00. No information
C10
11%
C30
17%
C40
29%
C50
10%
C60
4%
C70
24%
C00
5%
C80
0%
C20
0%
C10
6%
C20
4%
C30
8%
C50
8%
C60
10%
C70
25%
C80
2%
C40
38%
Fig. 5. The two distribution patterns, by the type of accident (variable contact).
Fig. 6 shows the accident pyramid for the whole reference sec-
tor, as well as the criteria for each level, starting from minor acci-
dents with no absence from work, up to fatal occurrences.
The numbers in bold show the ratio whilst the numbers in
brackets are the actual number of accidents registered in that year
(N = 1078). At this stage it is worthy highlighting a detail. There
were no fatal accidents in the period concerned (year 2005), as
there is no record of any fatality in the AA Shipyard in the past
two decades. Thus, the reference level used for calculating the ratio
was the level registering more serious injuries, i.e., the one leading
to higher absence from work: 181+ days lost.
Accident pyramids have important limitations, as discussed by
Hale (2001), but they are still useful tools for comparing the poten-
tial of fatality between different sectors of activity. The pyramids
progressing faster to the top level indicate a higher potential for
very serious or fatal outcomes. In this assessment, the same philos-
ophy is applied for comparing and ranking partial pyramids, each
representing a specic type of accident (i.e., the contact in the cen-
tre of each bow-tie diagram). Two examples are given in Fig. 7 for
the modalities of Contact C40 and C70 respectively. The absence of
fatal occurrences results in representations with only four levels.
The gure also shows that, despite the modality C40 (struck by ob-
ject in motion) is more frequent than C70 (physical or mental stress),
it holds a slightly lower potential to originate very serious out-
comes, since it progresses less rapidly to the top.
Applying the same criteria, the accident ratios were calculated
for each of the eight modalities of contact and the result of this
exercise is shown in Table 3. The bottom row of the table indicates
the scores given to the risk dimension potential seriousness. It could
be argued that the C70 pyramid progresses somewhat faster to the
top, when compared with those of C30, C40 and C50. For this rea-
son, it could be scored 5 to differentiate it from the others. How-
ever, the authors opted for giving it a score 4, based on the
following: (1) there were no fatalities in the period, (2) statistical
data from many other sectors reveal that C70 type of accidents
hardly result in a fatality, and (3) based on the matrix established,
a score 5 in the seriousness axis would not change the nal risk
level of this modality.
Returning to the specic case under consideration, with regard
to the risk of being struck by something (C40) during a steel blasting
operation, one will now conclude that likelihood (29%, Fig. 5)
and seriousness (Table 3) are both scored 4. Entering this infor-
mation in the risk-matrix (Table 2), it results in a classication of
very high risk. The occurrence of fatal accidents in the reference
dataset, in this case, would not have affected the risk level ob-
tained, since the frequency of this type of accident is already unac-
ceptably high.
The main advantage of this assessment approach is the reduced
dependency of subjective judgments from the analysts. As is, it al-
lows incorporating some level of objective evaluation, without
being necessarily quantitative.
Table 2
Risk matrix adopted for establishing the risk level
a
.
Scores and criteria Seriousness/potential severity of harm (days lost)
1 Slightly harmful 2 Moderately harmful 3 Very harmful 4 Extremely harmful 5 Fatal
1 Very unlikely (01%) Very low Low Low Medium High
2 Unlikely (29%) Low Low Medium High High
3 Likely (1020%) Low Medium High High Very high
4 Very likely (>21%) Medium High High Very high Very high
a
The asymmetry of the matrix is intentionally conservative (e.g.: one single label very low in contrast with four labels very high). At least until more abundant data is
available this offers higher protection to exposed workers.
Fatal
Minor injuries - No absence
30-180 days
181+ days
Up to 30 days lost
N total = 1 078
0
1 [16]
8 [122]
31 [498]
28 [442]
Fig. 6. Accident pyramid in sector 35.1 (2005 data) (ratio to serious accidents 181+
days).
C40 (~29%)
(Struck by object)
1[3]
6 [19]
45 [135]
53 [158]
1[7]
5 [37]
18 [124]
13 [89]
C70 (~24%)
(Physical or mental stress)
Fig. 7. Accident pyramids for the Top-2 modalities of contact (sector 35.1, 2005
data).
Table 3
The pyramids (ratios) of all modalities of contact (sector 35.1 in 2005).
C10 C20 C30 C40 C50 C60 C70 C80
Fatal
(a)
- - - - - - - -
181+
days lost
- -
1 1 1
-
1
-
30-180 days
lost
1
-
8 6 8 1 5
-
Up to 30
days lost
11
-
24 45 36 2 18
-
No lost time
27 1 14 53 7 2 13
-
Score for
Seriousness
2 1 4 4 4 3 4 1
a
The absence of score 5 in seriousness denotes the non-occurrence of fatal acci-
dents in this working population and in the reference period.
On the other hand, a current limitation is the fact that this type
of semi-quantitative assessment, based on aggregated statistics,
does not allowto differentiate the risk level between tasks. The risk
of being struck by object in motion, for instance, would always
be classied as a very high risk in the shipyard, which may not
necessarily be the case with other tasks. Such limitation can only
be overcome with time, as more accident data is accumulated for
each production process or task.
Another limitation of using the sectors aggregated statistics is
that the analyst does not know what barriers are already in place;
therefore one cannot estimate the impact of new barriers in the
system. Despite this, the bow-tie diagram keeps the virtue of
directing the analyst to identify the necessary barriers for each par-
ticular case. Within an organisation, people will be able to identify
which barriers are already in place and which are failing: either be-
cause they are missing or because they are not being used properly.
As such, it provides a means of improving the safety situation (and
current practice) even though there is no quantied way of assess-
ing the impact of such improvements. In any case, the diagrams
help to identify risk controls and to apply the ALARP principle even
without quantication.
5. Concluding remarks
This paper has discussed an application of the bow-tie approach
in a semi-quantitative assessment of occupational accident risks.
The methodology proposed was demonstrated through a case
study involving a particular type of accident likely to occur in a
shipbuilding yard, during the steel-blasting process. In this ap-
proach the critical event, in the centre of the diagram, is classied
through the Eurostat variable contact-mode of injury. This auto-
matically implies the construction of eight separate diagrams (one
for each modality of contact) for the analysis of each single task.
This requires more time than a classical all-embracing technique,
but it has the advantage of forcing the analyst to focus on a partic-
ular type of accident individually; it was felt that this process
encourages more detailed analysis and better explanations of the
possible pathways leading to each type of accident.
Overall, the method described here consists of a sequence of
two steps. The rst is strictly qualitative and uses the bow-tie dia-
gram as graphic tool for mapping the pertinent causes and conse-
quences of the accident type under analysis. A particularly useful
feature of this tool, even if used solely for qualitative analysis, is
its ability to direct the analyst to make a clear distinction between
prevention and protection/mitigation barriers for eliminating,
reducing or attenuating the effects of the specic accident risk.
The second step consists of a semi-quantitative estimation of risk,
based on a ve level risk-matrix. With the aim of reducing subjec-
tive judgment to a minimum, the criteria for scoring likelihood
and potential seriousness were derived from actual accident sta-
tistics of the activity sector 35.1 building and repairing of ships
and boats, used as the reference sector. In this step, the likeli-
hood of occurrence was scored through the frequency distribution
of the variable contact, whereas the scoring for potential seri-
ousness was established by crossing the data of the variables
contact days lost. It is believed that this scoring system, based
on realistic accident data, incorporates some level of objective
evaluation, without being necessarily quantitative.
Although the original bow-tie model is probabilistic and com-
plex in nature, this industrial application case demonstrates that
a simplied version of it can be successfully applied by individual
organisations in the eld of occupational safety and that it brings a
number of advantages over more traditional methods (e.g.: Task
Analysis or Energy Analysis). However, it has also revealed that,
probably only large organisations can afford using this systematic
tool, since its application in the eld seems to be more difcult
than the older techniques: not only it requires relatively more time
but also qualied safety professionals to run the analysis and build
the diagrams. In spite of this well succeeded rst trial, more re-
search will be required to allow a clearer distinction between the
different tasks.
Acknowledgments
The authors are grateful to Arsenal do Alfeite and its top man-
agement for their full cooperation in this work and for making
available all the necessary accident data and relevant information,
which was essential for carrying out this study. A word of gratitude
is due to the Portuguese Ofce of Strategy & Planning GEP (Gabin-
ete de Estratgia e Planeamento), of the Ministry of Labour and So-
cial Solidarity, for supplying the national accident data pertinent
to the Ship Building Sector.
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